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July 01, 2013

A Brief Survey of State POLST Form Distribution Practices

Jenica Cassidy

(Note: For a footnoted version of this article, complete with detailed table, please download the pdf issue of BIFOCAL Vol. 34, Issue 6.)

The POLST form is an advance care planning tool that documents the “Physician’s Order for Life Sustaining Treatment” process. It is a way to translate the wishes of a patient with an advanced, progressive illness into physician orders that must be followed by emergency personnel and other health care providers across all settings of care. The POLST form is based on an effort to make end-of-life health care planning for seriously ill individuals more person-centered, better coordinated across care settings, and focused on key critical decisions relevant to the patient’s current condition. At the same time, the process places a high priority on protecting vulnerable individuals for whom life and death decisions are made. POLST supplements other health care planning documents specifically for patients with advanced, progressive conditions.

POLST is in use or under development in over thirty states. Each state adheres to its own POLST document and procedures. While all states require a valid POLST form to be signed by a health care provider, they vary as to who qualifies as “health care provider.” In addition, the use of POLST requires a discussion between the treating health care provider and the patient or the authorized surrogate about end-of-life care treatment options. The nature and use of POLST poses an access challenge. In whose hands are POLST forms placed and how? Providing unlimited access to the POLST form—for example, by posting it online—is simple, cost effective, and in accordance with the POLST policy of patient autonomy and independence. However, providing unrestricted access to the POLST form may increase the likelihood of improper or ill-informed use. Making the form accessible to the general public without limitation may also increase the risk of confusing the form with other health care planning documents such as advance directives. Whether these concerns in connection with distribution of POLST forms have any merit has never been explored in research.

To acquire a baseline understanding of how POLST forms are distributed, this brief survey examined state policies and procedures regarding POLST form accessibility in the 16 states where the POLST program is either mature or endorsed as of July 2013. The survey examined program web sites and requested information on distribution policies and practices from state key contacts identified by the National POLST Paradigm Task Force.

The survey found that distribution requirements and procedures varied significantly across the states but generally fall into one of two categories: those that provide general public access to the POLST form without limitation, and those states that limit access to health care professionals only.

Of the sixteen states with a mature or endorsed POLST program, eleven offer the POLST form to the general public, without any restrictions, via a free-of-charge download off of the state’s participating website. Five states limit distribution to health care professionals. POLST is so new in some states, such as Georgia, that the state may not have developed a formal protocol for distribution of POLST form. Open accessibility of the form on a website may be the natural default option.

Design and color requirements also affect distribution options. One of the earliest hallmarks of the POLST paradigm is the use of a unique, brightly colored and easily visible document in a patient’s record. A POLST form printed on plain white, indistinguishable paper lacks that hallmark but simplifies access, copying, and use. States that mandate a specific color and paper type for printing purposes may provide greater assurances of form validity, integrity, and visibility, but they make access potentially more onerous and costly. In addition, as medical records move toward all-electronic formats, paper characteristics become increasingly archaic. Currently, of the 16 states, only North Carolina, Wisconsin, and West Virginia restrict distribution to mail order shipments of the form printed to the state’s color specifications.

Download the pdf issue of BIFOCAL Vol. 34, Issue 6 for the chart that summarizes the states’ distribution and access characteristics.

Jenica Cassidy

About the Author: Jenica Cassidy is a third-year law student at Wake Forest University School of Law in Winston Salem, NC, and served as a 2013 summer intern with the Commission on Law and Aging.